Thank you for completing and reviewing your intake forms and information.
- Your requested appointment time will be confirmed by email or by phone within 2 days of your appointment request by one of our Patient Educators.
- When you arrive for your appointment you will have an opportunity to review your pre-filled intake forms with a Patient Educator and sign them.
We encourage you to review the information presented during the intake process:
All forms are available below and in our Patient Center.
Administrative Consent Forms:
- HIPAA Privacy Practices Consent (English/Español)
- Insurance Release and Authorization (English / Español)
- List of Accepted Insurance Carriers (English / Español)
Medical Service Consent Forms:
- Authorization and Consent for Medical Treatment (English / Español)
- Anesthesia and Sedation Consent (English/Español) (Procedural Abortion Only)
Medical History Forms:
Thank you for trusting us with your wellness and we look forward to providing you with the best care,
Falls Church Healthcare Center